Provider Demographics
NPI:1609142447
Name:GREAT LAKES ANESTHESIA CONSULTANTS PLLC
Entity Type:Organization
Organization Name:GREAT LAKES ANESTHESIA CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIJ
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-324-8406
Mailing Address - Street 1:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0019
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:7901 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0714
Practice Address - Country:US
Practice Address - Phone:269-324-8406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty